New Medicare program using AI leaves WA patients in pain

Ten years ago, Keith Magnuson could easily walk 6 miles a day. Today, he can barely manage 100 yards.

The 83-year-old living in Seattle’s Cedar Park neighborhood has a condition called lumbar spinal stenosis. Put simply, the lower part of his spinal canal has narrowed over time, and the resulting pressure on his nerves causes pain whenever he walks or even stands for more than a few minutes.

“Anytime I’m on my feet, I’m hurting,” he said. On a clear March day, he sat on his couch looking out over the water, reminiscing about the activities he used to do – from water skiing to rock climbing.

There exists a treatment that could provide Magnuson with immediate and long-term relief called minimally invasive lumbar decompression, or “MILD.” The procedure has a high success rate and is relatively low-risk compared to surgery, Magnuson’s doctor told him. It’s also covered by his Medicare insurance, the public program for people over 65.

But Magnuson may not be able to get MILD any time soon.

That’s because at the start of 2026, Medicare launched a pilot program to review certain medical services for enrollees in Washington and five other states.

Late last month, it denied one component of Magnuson’s back treatment plan, effectively blocking him from getting his procedure done, he said.

Slated to run through 2031, the Medicare pilot aims to reduce spending on unnecessary care with the help of “enhanced technologies,” including artificial intelligence and machine learning, according to the program overview.

In practice, that means patients seeking certain medical services now have to wait for a third-party tech company to give them the green light before they can get treatment. The wait for approval can be long and disruptive.

The program represents a major shift for Medicare.

Unlike private insurance, Medicare historically has not required doctors to get approval before providing patients with covered treatments, a process known as prior authorization. The new program adds a first-of-its-kind layer of scrutiny for patients trying to get certain services, as well as for doctors attempting to provide care.

Although the program is currently limited in scope, future expansions to include other services and regions could lead to more care getting denied or abandoned.

In the meantime, as the initiative’s rollout has been rocky across Washington, patients and doctors say that vulnerable people – people who are older, sick or in pain – are the ones paying the price.

“It’s frustrating and depressing,” Magnuson said, sitting on an ergonomic seat cushion at his kitchen table. “It’s robbing me of quality of life.”

‘An administrative headache’

In June, the federal agency that runs Medicare announced a pilot program called the “Wasteful and Inappropriate Service Reduction” model, or “WISeR.”

WISeR would protect taxpayer dollars by denying people costly and unnecessary medical care, said Mehmet Oz, administrator of the Centers for Medicare and Medicaid Services.

A few months later, the program took effect across six states, including Washington. It is currently limited to 13 specific medical services, which CMS chose based on what it determined as vulnerability to fraud, waste and abuse, according to the agency.

Under WISeR, doctors in Washington who want to treat Medicare patients with one of the 13 services now must first obtain prior authorization through a contracted tech company.

The contractor reviews the service based on Medicare coverage rules with the help of “enhanced technologies, including artificial intelligence,” according to CMS. Doctors can choose not to get prior authorization, but doing so means they risk not getting paid by Medicare for their services.

In Washington, the program is off to a shaky start.

The state’s WISeR contractor is Virtix Health, a Phoenix-based tech company.

Virtix is expected to give doctors prompt approvals or denials, with response times under 72 hours, according to CMS.

Health care groups in Washington say that some requests are taking much longer.

“That’s actually a pretty big issue for our patients and for our hospitals,” said Jennifer Brackeen, senior director of government affairs for the Washington State Hospital Association, which represents hospitals and health systems in the state. “I think the intent by having AI is that it would be quicker. But we’re just not seeing that in Washington.”

For Northwest Endovascular Surgery in Benton County’s Richland, prior authorization turnaround times were stretching up to two or three weeks as recently as mid-February, according to Yasamin Alazawi, an intern and scrub technician who is responsible for submitting the office’s requests to Virtix.

Alazawi said that Virtix is now responding to requests usually within a week. But that’s not all. Before a procedure can take place, doctors offices need to get a unique authorization number from Virtix. That can add another two or three business days.

“When I tell the patient, ‘We’ll need to keep waiting,’ I can just hear them sigh on the phone or even tear up because of how much pain they’re in,” Alazawi said. “The best way I can describe it is desperation.

Virtix acknowledged delayed responses in the program’s early weeks, as well as the impact of those delays on patients. The company said in an email to the Seattle Times on Tuesday that those were caused by an unexpectedly high volume of prior authorization requests.

“We remain committed to meeting the program’s timeliness standards and are continuing to invest in provider education and operational improvements to that end,” read the company statement.

CMS said in an email on Tuesday that the agency monitors turnaround times, and that delays can result in “corrective action.”

“CMS continues to review stakeholder feedback and will refine model operations as appropriate,” CMS wrote.

Private insurers have long required doctors to submit requests for prior authorization, which determines whether a patient is eligible for a medical procedure. But prior authorization systems may issue erroneous denials.

Virtix said that AI is used only to approve prior authorization requests. All denials must go through clinicians, who also monitor the accuracy of the company’s AI tools.

“No patient is denied care by an algorithm – every non-affirmation involves a board-certified physician,” the company said.

Denials can happen when a prior authorization request lacks all necessary documentation, the company said. Doctors can resubmit requests; they can also schedule a peer-to-peer review to discuss a denial with a Virtix-employed physician.

Taken together, this can translate to hours of additional time spent tracking and troubleshooting requests, said Jeb Shepard, director of policy at the Washington State Medical Association, which represents physicians and physician assistants in the state.

“The long and short of it is just that this is an administrative headache,” Shepard said.

Months of pain

Some medical providers are more impacted by the Medicare pilot program than others due to the type of medicine they practice. Pain management is one such specialty.

Magnuson, the Cedar Park resident with lower-back pain, is tentatively scheduled for his MILD procedure in early April, even though he does not have an approval yet.

During MILD, his doctor intends to give him an epidural steroid injection, Magnuson said. Epidural steroid injections are commonly used to address lower back pain. They’re also one of the 13 services included in the WISeR pilot.

On February 24, Virtix denied Magnuson the epidural steroid injection, according to a timeline of events taken by Magnuson’s wife, Annie.

The denial of a single medical service risks delaying Magnuson’s whole treatment plan, his doctor’s office told him.

Magnuson is not sure why the injection was denied. His doctor has since requested a peer-to-peer review with Virtix. (Magnuson’s doctor declined to speak with the Seattle Times.)

Independent pain physicians who spoke with the Seattle Times say that an epidural steroid injection is a reasonable medical service to include as part of MILD.

“I think it’s kind of ridiculous that it wouldn’t be covered in the context of MILD,” said Ryan Meral, a clinical assistant professor specializing in pain medicine at the University of Michigan. When Meral performs MILD, he adds an epidural steroid injection, which, he says, can help reduce inflammation and alleviate pain. “If that’s my mom on the table, that’s what I would want.”

Not all doctors perform MILD the same way.

Gerard Limerick, an assistant professor of physical medicine and rehabilitation at Johns Hopkins University, does not typically add an epidural steroid injection when performing MILD. But he said doctors practice differently based on judgment and experience. “I don’t think that including the epidural as part of the MILD procedure constitutes waste or excess,” he said.

Magnuson’s experience is not an isolated incident.

Sarah Oman has been trying to help her 78-year-old father get treatment for back pain. In January, his doctor recommended an epidural steroid injection, which Oman’s father had received in the past, Oman said. Prior injections had helped to reduce inflammation around his spinal cord and enabled him to walk without pain for several months.

Oman’s father used to get the procedure done within days of seeing a doctor. Now, he’s been waiting for two months and counting because of the Medicare pilot program, according to Oman.

WISeR denied his doctor’s request for the service, and the doctor’s office recently resubmitted the request, she said in an interview this month.

Even if the request is ultimately approved, Sarah said that the pilot program has already inflicted harm on her father simply by delaying a service that could have saved him months of pain.

“He would have been able to walk more, sleep better,” she said. “I checked in with him on how he was doing. He said it’s the worst thing that he lives with.

On average, Medicare pays $380 for the epidural steroid injection that Oman’s father is waiting on, when performed at a nonhospital facility, according to the insurance program’s price lookup tool.

Oman questions whether those savings are worth the wait her father continues to endure, and the additional administrative work that his doctor’s office now has to handle.

“It’s actually jaw-dropping to me right now to realize that that’s the amount of money that Medicare has put this office through to avoid paying,” Oman said.

Before the WISeR pilot, the onus was on doctors to ensure that their services were medically necessary. Medicare can audit doctors and claw back money from those who cannot prove that a medical service was justified.

Under WISeR, doctors now have to provide that evidence up front when it comes to the 13 services included in the pilot program.

Brent Richardson, a doctor at Mt. Baker Pain Clinic, understands the perspective of an insurer like Medicare: the program can help control spending. For patients, though, administrative hurdles can become barriers to getting relief.

Even though Richardson has been successful at appealing many WISeR denials, he said the process is slowing down care.

“That’s never a particularly good thing, especially in pain medicine when somebody hurts,” he said. “They want that pain to be relieved yesterday not two months from now.”

‘Really upsetting’

Magnuson was originally scheduled to have the MILD procedure done last year, but had to delay treatment because of other health complications, including a knee replacement that was later infected and a broken hip.

Had he gone ahead with MILD then, he would have never had to confront the WISeR review process, which did not begin until this year.

Before WISeR, receiving an epidural steroid injection was a decision more commonly made between a doctor and a patient alone.

In May, Jaisri Lingappa, 67, developed sciatica, severe pain that started in her lower back and ran down her left leg.

The Port Townsend resident had never suffered from back pain before then. But the condition quickly became so excruciating that it prevented her from sleeping for more than two hours at a time. In August, she saw a specialist who recommended an epidural steroid injection. She got it done six days later and felt progressive relief over the next 10 days; it hasn’t come back.

But Lingappa is terrified that the pain will eventually return. “Now with WISeR, I could potentially be in a situation where I’d have to wait weeks potentially for prior authorization,” she said. “It’s just really upsetting to me.”

WISeR pays Virtix a percentage of the money it saves Medicare, according to CMS. That could put the program’s aims at odds with the well-being of Medicare enrollees.

“There is some concern that those incentives are not aligned with getting people the best care as quickly as possible,” said Jeannie Fuglesten Biniek, associate director for the Program on Medicare Policy at KFF, a research organization.

Discouraged by WISeR delays and denials, some patients may give up on receiving care through Medicare. Those who can afford it might look for ways to get treatment and pay for it out of pocket.

Magnuson spends $443 per month on his Medicare premium and another $302 per month on supplementary insurance, for a total of almost $9,000 on premiums per year.

Despite all that, Magnuson is seriously considering paying for treatment out of pocket. That won’t be easy, though. Doctors who participate in Medicare are prohibited from billing enrollees directly for services covered by the insurance program, such as the MILD procedure and epidural steroid injections.

Magnuson’s wife Annie points out that the WISeR pilot program, meant to eliminate waste, has simply created new burdens for doctors and patients alike.

“You think this is not waste?” she said. “Wasting everybody’s time on something that would have just happened.”

Without an alternative, Magnuson spends most of his time indoors and seated. Annie hates to leave him by himself, because she feels guilty going out when he cannot join.

On the walls of their home hang photos of Magnuson water-skiing as recently as four years ago and rock climbing as recently as last year. Now, he just wants to be able to do daily tasks, to visit the San Juan Islands, to take walks with Annie.

He takes a low dose of oxycodone daily to manage his pain. But he doesn’t want to hurt any longer. “Why are we waiting?”